Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Campus
Isabela State University
College of Medicine
Department of Anatomy
SY 2023-2024
Anatomy of the Pleura by Dr. Aries S. Garin, FPATACSI
Overview
The pleura is a double-layered serous membrane that covers each lung and lines the thoracic cage. The
outer layer (parietal pleura) attaches to the chest wall. The inner layer (visceral pleura) covers the lungs,
neurovascular structures of the mediastinum and the bronchi. The space between the parietal and
visceral pleurae is called the pleural cavity which contains a small amount of serous fluid (pleural fluid).
It is important to note that there is no connection between the right and left pleural cavities.
Figure 5.3 Pleurae from above and in front. Note the position of the mediastinum and the hilum of each lung.
Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Campus
The paired pleurae and lungs lie on either side of the mediastinum within the thoracic cavity (see Fig.
5.3). Each pleural membrane has two parts: a parietal layer and a visceral layer. The parietal layer lines
the thoracic wall, covers the thoracic surface of the diaphragm and the lateral aspect of the
mediastinum, and extends into the root of the neck to line the undersurface of the suprapleural
membrane at the thoracic outlet. The visceral layer completely covers the outer surface of the lung and
extends into the depths of the interlobar fissures (Figs. 5.5 and 5.6; also see Figs. 5.1, 5.3, and 5.4). It is
thinner than the parietal layer.
Figure 5.5 Different areas of the parietal pleura. Note the cuff of pleura (dotted lines) that surrounds the structures
forming the root of the left lung at the hilum. The parietal and visceral layers of pleura become continuous here.
Arrows indicate the position of the costodiaphragmatic recess.
Layers and Cavity
The two layers are continuous with one another via a cuff of pleura that surrounds the structures
entering and leaving the lung at the hilum of each lung (see Figs. 5.3 to 5.5). This cuff hangs down as a
loose fold called the pulmonary ligament and allows for movement of the pulmonary vessels and large
bronchi during respiration (see Fig. 5.5).
Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Campus
The parietal and visceral layers of pleura are separated from one another by a slitlike space, the pleural
cavity (see Figs. 5.3). The pleural cavity normally contains only a small amount of tissue fluid, the pleural
fluid. Pleural fluid covers the surfaces of the pleura as a thin film, which causes surface tension adhesion
of the pleural layers and permits them to move on each other with minimal friction. Thus, the pleural
cavity is a potential space under normal conditions and is discernible only under abnormal conditions
(e.g., when the lung is displaced by air or excess fluid).
For purposes of description, the parietal pleura is divided according to the region in which it lies or the
surface that it covers (see Figs. 5.3 and 5.5). The cervical pleura (cupula) extends up into the neck, lining
the undersurface of the suprapleural membrane. It reaches a level of 1 to 1.5 in. (2.5 to 4 cm) above the
medial third of the clavicle. The costal pleura lines the inner surfaces of the ribs, the costal cartilages, the
intercostal spaces, the sides of the vertebral bodies, and the back of the sternum. The diaphragmatic
pleura covers the thoracic surface of the diaphragm. In quiet respiration, the costal and diaphragmatic
pleurae are in apposition to each other below the lower border of the lung. In deep inspiration, the
margins of the base of the lung descend, and the costal and diaphragmatic pleurae separate. This lower
area of the pleural cavity into which the lung expands on inspiration is referred to as the
costodiaphragmatic recess (see Figs. 5.4 and 5.5). The mediastinal pleura covers and forms the lateral
boundary of the mediastinum. It reflects as a cuff around the vessels and bronchi at the hilum of the
lung and here becomes continuous with the visceral pleura. Thus, each lung lies free except at its hilum,
where it is attached to the blood vessels and bronchi that constitute the lung root.
The costodiaphragmatic recesses are slitlike spaces between the costal and diaphragmatic parietal
pleurae that are separated only by a capillary layer of pleural fluid. During inspiration, the lower margins
of the lungs descend into the recesses. During expiration, the lower margins of the lungs ascend so that
the costal and diaphragmatic pleurae come together again.
The costomediastinal recesses are situated along the anterior margins of the pleura. They are slitlike
spaces between the costal and mediastinal parietal pleurae, which are separated by a capillary layer of
pleural fluid. During inspiration and expiration, the anterior borders of the lungs slide in and out of the
recesses.
Nerve Supply
The pleural layers are innervated differently despite being a continuous membrane. Somatic afferent
nerves supply the parietal pleura (Fig. 5.7), which is sensitive to pain, temperature, touch, and pressure:
The intercostal nerves segmentally supply the costal pleura.
The phrenic nerve supplies the mediastinal pleura.
The phrenic nerve supplies the diaphragmatic pleura over the dome, and
the lower intercostal nerves supply the periphery of the diaphragmatic pleura.
Visceral afferent nerves supply the visceral pleura, which is sensitive to stretch but is insensitive to
common sensations such as pain and touch. These nerves run in company with autonomic nerves from
the pulmonary plexus.
Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Campus
Figure 5.7 Diagram showing the innervation of the parietal and visceral layers of pleura.
Arterial supply :
Parietal pleura
Costal pleura: small branches of intercostal arteries
Mediastinal pleura: supplied by pericardio-phrenic artery
Diaphragmatic pleura: supplied by superior phrenic and musculophrenic artery
Visceral pleura
Bronchial artery: supplies visceral pleura facing the mediastinum, pleura
covering the interlobular surface and part of the diaphragmatic surface
Pulmonary artery: supplies remaining portion
Venous drainage :
Parietal pleura
through the intercostal veins which empty into inferior vena cava or brachio-
cephalic trunk.
Visceral pleura
through pulmonary veins.
Applied anatomy: Aspiration of any fluid from the pleural cavity is called thoracentesis. It is usually done
in the 6th intercostal space in the midaxillary line. The needle is passed through the lower part of the
intercostal space to avoid injury to the neurovascular bundle.
Lymphatic Drainage
Lymphatic vessels in parietal pleura are in communication with the pleural space by means of stoma.
Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Campus
Stoma
2-6 mm in diameter
round or slit like opening
found mostly on the mediastinal pleura and on the intercostal surfaces.
more stoma in the area where the mesothelial cells are cuboidal rather then flat.
Lacunas
lymphatic vessels in parietal pleura have many branches, some submesothelial branches have
dilated lymphatic space called lacunas.
stomas are found only over lacunas.
Applied anatomy: Stomas with their associated lacunas and lymphatic vessels are main pathway for
elimination of particulate matter from pleural space. This transport system may provide a mechanism for
migration of malignant cell to distant organs in patients with positive pleural lavage cytology.
Embryology:
Pleural cavity
Derived from the coelomic cavity (body cavity)
Coelomic cavity divided into pericardium, pleural cavities and the peritoneal cavity through the
development of three sets of portions :
- Septum transversum : serves as an early partial diaphragm.
- Pleuro pericardial membranes : divide pericardial and pleural cavities.
- - Pleuro peritoneal membranes : unite with the septum transversum to
complete the partition between each pleural and peritoneal cavity.
Pleural cavity is fully lined by mesothelial membrane, the pleura.
Histology:
thin, single cell layer
specialized squamous-like cells, called mesothelium
6-12mm thickness
microvillae present to decrease friction
stomata present between the mesothelial cells that communicate directly with lymphatic
lacunas.
Clinical Correlation:
Pleurisy
Inflammation of the pleura (pleuritis or pleurisy), secondary to inflammation of the lung (e.g.,
pneumonia), results in inflammatory exudate coating the pleural surfaces, which causes roughening of
the surfaces. This roughening produces friction, which can be heard with the stethoscope as a pleural
rub on inspiration and expiration. Fibroblasts often invade the exudate, resulting in deposition of
collagen and formation of pleural adhesions that bind the visceral pleura to the parietal pleura.
Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Campus
Pneumothorax, Empyema, and Pleural Effusion
Air can enter the pleural cavity from the lungs or through the chest wall (pneumothorax) as the result of
disease or injury (e.g., interstitial lung disease, gunshot wounds). In the old treatment of tuberculosis, air
was purposely injected into the pleural cavity to collapse and rest the lung. This was known as artificial
pneumothorax. A spontaneous pneumothorax is a condition in which air enters the pleural cavity
suddenly without its cause being immediately apparent. Investigation usually reveals that air has entered
from a diseased lung and a bulla (bleb) has ruptured.
Wounds that penetrate the thoracic wall (e.g., stab wounds) may pierce the parietal pleura so that the
pleural cavity is open to the outside air. This condition is called open pneumothorax. Each time the
patient inspires, it is possible to hear air under atmospheric pressure being sucked into the pleural cavity.
Sometimes, the clothing and the layers of the thoracic wall combine to form a valve so that air enters on
inspiration but cannot exit through the wound. In these circumstances, the air pressure builds up on the
wounded side and pushes the mediastinum toward the opposite side. In this situation, a collapsed lung
is on the injured side, and the opposite lung is compressed by the deflected mediastinum. This
dangerous condition is called a tension pneumothorax.
Air in the pleural cavity associated with serous fluid is known as hydropneumothorax, associated with
pus as pyopneumothorax, and associated with blood as hemopneumothorax. In hemopneumothorax,
trauma to the chest may result in bleeding from blood vessels in the chest wall, from vessels in the chest
cavity, or from a lacerated lung. A collection of pus (without air) in the pleural cavity is called an
empyema thoracis. The presence of excess serous fluid in the pleural cavity is referred to as a pleural
effusion. Fluid (serous, blood, or pus) can be drained from the pleural cavity through a wide-bore needle
via a procedure known as thoracentesis.
Chylothorax
A chylothorax is the accumulation of chyle in the pleural space. This is most commonly seen following
traumatic disruption of the thoracic duct and is typically diagnosed based on the milky appearance of
fluid due to high-fat content. Most patients with chylothoraces will require surgical exploration of the
thoracic duct. Chylothorax has no predilection for gender or age.
Anatomy References:
1. Wineski, L.E., 2019, Snell’s Clinical Anatomy by Regions, 10th ed, Wolters Kluwer
2. Stranding, S., 2016, Gray's Anatomy: The Anatomical Basis of Clinical Practice, 41st ed,
Elsevier Limited
3. Netter, F.H., 2019, Netter's Atlas of Human Anatomy 7th ed, Elsevier Inc.
